RELEASE OF INFORMATION - I, the below named patient, do hereby authorize any physicians examining and/or treating me to release to any third party including payors such as an insurance company or governmental agencies, e.g. Blue Cross Blue Shield or Medicare, any medical, psychiatric condition, alcohol or drug related condition and records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for payment for such treatment and/or diagnosis. I further understand that HIPAA and other Laws allow for release of information without authorization for the purposes of treatment, payment, or operations.

PHYSICIAN INSURANCE ASSIGNMENT — I, the below named subscriber, hereby authorize payment directly to any physician examining or treating me or any group and/or individual surgical and/or medical benefits herein specified and otherwise payable to me for their services as described but not to exceed the reasonable and customary charge for these services.

MEDICARE/MEDICAID — I certify that the information given by me in applying for payment under Title XVIII and XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration, Division of Family Services or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. I hereby certify all insurance pertaining to treatment shall be assigned to the physician treating me.

PERMIT A COPY - This authorization and assignments to be used in place of the original, which is on file at the provider's office or EMR. The assignment will remain in effect until revoked by me in writing.

FINANCIAL RESPONSIBILITY — I understand that I am ultimately responsible for full payment to the provider. I understand that providers may accept fixed allowances or reimbursement based on a fee schedule etc from third-parties such as insurance.